Healthcare Provider Details

I. General information

NPI: 1215900378
Provider Name (Legal Business Name): AZURE MARIE BUCKENBERGER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 W COURT ST CHC LA CLINICA
PASCO WA
99301
US

IV. Provider business mailing address

PO BOX 1323
PASCO WA
99301
US

V. Phone/Fax

Practice location:
  • Phone: 509-547-2209
  • Fax: 509-544-8768
Mailing address:
  • Phone: 509-547-2209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH00006861
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: